Parents Blame Lack of Primary Care Access for Most Kids' ER Visits

Study surveyed parents who brought their children to an emergency department

NEW YORK (Reuters Health) -- Having a medical home was not associated with a reduced likelihood that parents would take their child to an emergency department (ED), but most parents who made such a visit said it could have been avoided if primary care had been readily accessible, according to a cross-sectional study.

The researchers, from the University of Iowa in Iowa City, analyzed data from the 2010-2011 Iowa Child and Family Household Health Survey, a statewide population-based sample of Iowa families with at least one child. Of the 3000 eligible families, 2386 completed the survey, a response rate of about 80%.

Of the 1409 respondents who reported needing some form of medical care for their child in the past year, 371 (26%) said they took their child to an ED at least once during that time, the researchers reported online August 6 in Emergency Medicine Journal.

"The major finding was that about 70% of the parents who took their child to an ED perceived that the ED visit could have been avoided if a primary care provider (had been) available," Dr. Astha Singhal told Reuters Health by email. "This is a huge proportion of parents, who are the decision-makers with respect to their child's healthcare, highlighting that more pediatric ED visits could be avoided than was previously thought."

Children from food-insecure households and children with a poorer reported health status were significantly more likely to visit an ED (adjusted odds ratio 1.69 and 1.63, respectively).

In the researchers' multivariable logistic regression analysis, parents of children on public insurance were nearly twice as likely as those with children on private insurance to report an avoidable ED visit (adjusted OR 1.76).

Similarly, parents who said they weren't always able to get an appointment for routine care for their child as soon as they wanted it were twice as likely to perceive an ED visit as avoidable (adjusted OR 2.03).

This finding "underlines the key hypothesis of the importance of continuous and regular access to primary care in reducing ED visits," said Dr. Singhal, now of the Boston University Henry M. Goldman School of Dental Medicine.

About 36% of children with ED visits were referred to the ED by a health care provider, and more than half of these children's parents said they thought that the ED visit could have been avoided if a primary care provider had been available.

"We were very concerned about this finding, but given the limitations of secondary data, we could not distinguish actual referrals from nurse helpline messages or automatic recorded after-hours messages from (primary care) office phones," Dr. Singhal said.

In the 5 years or so since the data were collected, there have been several changes in the United States that might have increased access to primary care, she noted, such as enhanced primary care under provisions of the Affordable Care Act and the proliferation of urgent-care centers and retail clinics.

Low-income families still have comparatively fewer resources to access the expanded safety net and primary care, Dr. Singhal noted. "However, having after-hours access would greatly improve the ability of parents who work multiple jobs to access care."

Having a medical home has been proposed as one way to reduce ED visits, but it's probably not surprising that the study did not find this, Dr. Alfred Sacchetti, a spokesperson for the American College of Emergency Physicians, told Reuters Health by email.

"Having a primary care provider is not the same as access to primary care," Dr. Sacchetti said. "There is a difference between 'Come in right away, we'll take a look at the child now' and 'Our next opening is tomorrow at 8:00 pm.'"

One should consider including the ED as part of a patient's medical home, Dr. Sacchetti said. "The ED is always open, the lights are on, the staff is there. Take advantage of it and offer it as an alternative to a delayed visit to the pediatrician's office."

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